Big Trouble

[Bentlysnurse]

Hello Nurses,

This might be long so bare with me!! I am quite distraught at the moment and need your help. I am a relatively new nurse that works in the Medical ICU. Working in the ICU as a new grad has been a huge learning curve but exciting.

When it comes to the ICU you administer a lot of medications specifically pain medications. I was recently pulled into my managers office with concerns of my documentation with one specific IV pain med. The most prevalent pain med we give. The problem was that some how some way it had come up in my documentation that I had scanned the pain med as if I had given it in our e-chart (Prism), then later on it saying I pulled that med from the Med station making a time stamp. So Me documenting at 0400 that I gave the med, and then at 0430 it showing I took it from the med station.

My manager has put me on leave because this has come up in my charting almost 5 times on different patients. I get very busy and caught up in my pt care but she wants an explanation of why I did this. The problem is I honestly don't know why I would scan a med before pulling it.

If there is anyone out there that would have a reasonable / any explanation I really need your help!! I love my job and my pts and I would hate myself if I lost it over this.

Thank you for all the help!

[MunoRN, RN]

I've seen a similar situation where a manager got all bent out of shape because everyone was charting their medications as given in the EMR before the pyxis said the meds had been removed, I asked her to come look at what time the pyxis thought it was right now, which turned out to be 3 hours off.

[~Mi Vida Loca~RN, ASN, RN]

I've seen a similar situation where a manager got all bent out of shape because everyone was charting their medications as given in the EMR before the pyxis said the meds had been removed, I asked her to come look at what time the pyxis thought it was right now, which turned out to be 3 hours off.

That was happening for multiple people though correct, not just you?? I mean that was everyone's first guess except it seemed to only happen to this poster and not only a handful of times.

[JerseyTomatoMDCrab, BSN]

OP, we have lots of questions. Please clarify.

[delawaremalenurse]

so....I'm confused. How is a med being scanned to be given to a pt if it's supposedly not yet been pulled from the Pyxis? And no one else is having this issue?

If I had a suspicious mind I might be inclined to think you scanned the med at some point, administered it to the pt, kept the bottle/packaging etc., are now re-scanning the empty bottle/packaging/etc, then going to the Pyxis to pull another dose to use in a manner other than intended

Being under suspicion and possible investigation for diversion is a major event...I hope you are seeking appropriate counsel.

[traumaRUs, MSN, APRN]

Moved to MICU/SICU nursing

[Meriwhen, ASN, BSN, MSN, RN]

Or if you had a vial from waste. So let's say patient had 1mg Dilaudid ordered at 1400. You have 2 mg vials only. So you gave the 1mg and instead of wasting the other kept the vile. Patient now has 1mg Dilaudid due at 1500 so you pull out same vial and give the other 1mg now leaving you with an order for more Dilaudid in the med machine and the ability to pull out a new 2mg vial not thinking about the fact your times are going to be off and that you have no valid reason to pull out the second vial.

Or same scenario but there is no waste because the order is 2mg and you give but again hang on to vial and then scan to give again although there would be nothing to give. Then pull out.

I have to admit that I didn't think of that, probably because I'm in psych and not critical care. We don't keep IV or IM painkillers around (except Toradol), and when Ativan or Valium IM is ordered, most of the time it's a 2mg or 5mg dose, so there's nothing left to waste or save until the next dose.

When I do waste, I got into the habit of wasting meds ASAP in the Pyxis, either as I draw it out or immediately after administration. It makes things so much easier since I don't have to keep track of it nor will I forget it. And there's never been a nurse that was too busy to pop in for a minute to witness a waste. If OP hasn't developed that habit, they ought to.

I also hope OP comes back with an update. Or at the least, OP has realized what serious **** he/she could be in and takes correcting it just as seriously.

[Bentlysnurse]

Hello everyone,

I appreciate all the feedback. Sorry for such a late reply. Ive been following up on all your feedback and seeking a lawyer in thought that this could turn south fast. In reply to everyone thinking of suspicious activity. Coming from my lack of experience I hadn't even given much thought of the possibility of diversion. Why would documenting a med be given then go and pull it? To me that would be a very stupid and careless way of diverting a med. In regards to JKL33 and others who mentioned this. My orientation was not adequate especially for being a new nurse and in the icu. I didn't have a designated preceptor(new preceptor each shift) every nurse provided care and documented in their own way. I was hired by different more supportive managers then the ones I have now. I didn't have any post orientation meeting or any chance really to express my concerns to my managers being on night shift. Ive never really felt supported by management or my fellow peers besides a few. And when I had the chance to express my concerns I didn't feel like they acknowledged me and all they offered was to give me a few resource websites. And no actual hands on time. I've had a hard time balancing my charting and providing the best care I can. I was always told that pt care comes before documenting. After reading all the replies the most logical explanation to me was that I must of had an empty vial or manually entered the med in anticipation of giving it later. I always felt anxious about Keeping my pt sedated enough and not to go crazy about having a tube down their throat. So I liked to Be prepared and not have to worry about documenting. I know that isnt good practice at all and I'm never going to do it again. I just feel I wasn't properly prepared for the icu and given a second chance I believe I should be on a med surg unit to gain better time management. But I have not yet met with my manager about this due to her being busy. But I hope this won't be the end of my career. I love nursing. Thank you all for your replies.

[meanmaryjean, DNP, RN]

Your post casts a lot of blame on others, and your 'explanation' of "After reading all the replies the most logical explanation to me was that I must of had an empty vial or manually entered the med in anticipation of giving it later" still does not explain why only one specific drug.

Do you not remember what you did? I find that VERY difficult to believe OP.

[OrganizedChaos, LVN]

How was it scanned first, the Pyxis then said it was pulled & why is it the same medication??? I've never worked in a hospital or with a Pyxis but something feels off/left out.

[OrganizedChaos, LVN]

Your post casts a lot of blame on others, and your 'explanation' of "After reading all the replies the most logical explanation to me was that I must of had an empty vial or manually entered the med in anticipation of giving it later" still does not explain why only one specific drug.

Do you not remember what you did? I find that VERY difficult to believe OP.

I agree. In the OP & her follow up post she never once takes the blame. She places the blame on her preceptor/manager/whoever. They didn't teach her to make the mistake nor were they they when she made the mistake.

[Meriwhen, ASN, BSN, MSN, RN]

Hello everyone,

I appreciate all the feedback. Sorry for such a late reply. Ive been following up on all your feedback and seeking a lawyer in thought that this could turn south fast.

Good.

In reply to everyone thinking of suspicious activity. Coming from my lack of experience I hadn't even given much thought of the possibility of diversion. Why would documenting a med be given then go and pull it? To me that would be a very stupid and careless way of diverting a med.

There isn't always a rhyme or reason regarding how people divert. Some are very crafty and thoroughly think through how they divert. Some are less meticulous or too deep in the throes of addiction--that they don't care--or no longer care--how they obtain their desired med. When you're jonesing for a high, you don't necessarily want to pay attention to the details because that's not your focus--getting and using the drug is your focus.

So while you may consider it a "stupid and careless way" of diverting a med, the fact is that that way is more common than you think. And employers know that.

In regards to JKL33 and others who mentioned this. My orientation was not adequate especially for being a new nurse and in the icu. I didn't have a designated preceptor(new preceptor each shift) every nurse provided care and documented in their own way. I was hired by different more supportive managers then the ones I have now. I didn't have any post orientation meeting or any chance really to express my concerns to my managers being on night shift. Ive never really felt supported by management or my fellow peers besides a few. And when I had the chance to express my concerns I didn't feel like they acknowledged me and all they offered was to give me a few resource websites. And no actual hands on time.

OP, I say this very gently. You are not longer in nursing school where you have the safety net of your clinical instructors. You have graduated and you hold a nursing license. From the moment that license was issued, YOU are 100% responsible for your nursing practice. Not your employer, not the preceptors you had, not your managers. But YOU.

So while you can cast blame on anyone and everyone--and I'm not saying they didn't contribute to this in any way--the fact remains that YOU are ultimately responsible of the way you practice and the decisions you made. You need to be honest with yourself about that, and spend less time trying to cast blame on others.

I've had a hard time balancing my charting and providing the best care I can. I was always told that pt care comes before documenting. After reading all the replies the most logical explanation to me was that I must of had an empty vial or manually entered the med in anticipation of giving it later. I always felt anxious about Keeping my pt sedated enough and not to go crazy about having a tube down their throat. So I liked to Be prepared and not have to worry about documenting. I know that isnt good practice at all and I'm never going to do it again.

But you did it. Your manager didn't force you to do things this way. Your preceptors didn't force you to do things this way. No one had held a gun to your head and forced you to do things this way. YOU chose of your free will do to do things this way.

And I'm not unsympathetic, really I am not. I was a new grad once--we all were. I know the frustrations of having to learn under less than ideal circumstances, of having to get everything done correctly and on time, on figuring out ways I can improve that...and the temptations of cutting corners and using workarounds, especially when you see your coworkers doing such things.

But the name on my nursing license is Meriwhen, RN. No one else's name is on there with mine. So if I **** up because of my poor decision making, it's ultimately my responsibility and I have to face and accept the consequences, like it or not. It doesn't matter if I'm on day 1 or day 2546 of my career as a nurse--my practice is 100% my responsibility.

So my practice is determined by that realization. And yours needs to be to.

I just feel I wasn't properly prepared for the icu and given a second chance I believe I should be on a med surg unit to gain better time management. But I have not yet met with my manager about this due to her being busy

Perhaps you are right--you may not yet be ready for the ICU. The ICU has a steep learning curve and isn't always the ideal place for a new grad, especially if you didn't go through a new grad program/residency. A lot of new grads make it in the ICU, but a lot also crash and burn because it's too much too soon.

Your first year of nursing, a.k.a. Nursing 101, is not just about learning your specialty. It's about learning the things that they mention but don't really go into detail on: managing multiple patients, time management, delegation, planning and coordinating care, decision making, charting, and learning how to practice nursing in the real world (as opposed to the NCLEX's ivory tower perfect world). It's tough enough to learn these things in any specialty--to have to learn them on top of working in any form of ICU can be doubly hard.

Asking to transfer to med-surg so you can work on your skills and development is a good idea, IMO. But don't think that med-surg will be easy-peasy either. You'll be working just as hard as you did in the ICU, but the patients won't be as severely acute and you'll have a little more wiggle room.

But I hope this won't be the end of my career. I love nursing. Thank you all for your replies.

I also hope it won't end it. But you've got a lot to address right now. Start with squaring away the most immediate problem: the narcotic discrepancies, because this is where your license is on the line. Again, it's good that you're talking to an attorney.

I will tell you that nursing with a disciplined license is very tough because a lot of employers aren't as willing to take a chance on you...not when there's a ton of nurses with unblemished licenses who are ready to work yesterday. Discipline on your license is public knowledge, as in it could be seen when anyone searches the BON website for your license information. And discipline is forever--it never falls off your license after X years, it can never be removed, it just never goes away. A new grad with a disciplined license is a bad combination.

Nursing with a suspended or revoked license is impossible...well, it's possible but also highly illegal.

Best of luck sorting this out.

[JKL33]

Well, I've never been mistaken for a bleeding heart but...

Fourth take: Still believing this as told.

I believe the medication administration discrepancy issue as told by the OP doesn't make sense to us because HE doesn't know exactly what happened.

And I 100% believe this orientation experience as described; in fact it's exactly what I suspected when I posted earlier in the thread.

OP - - I say this in the spirit of constructive criticism: You sound extremely disorganized at best. Careless. Also, you have not gained the clinical/knowledge foundation that you *must have* in your role. I don't know what you can do about it now. My only suggestion is that you communicate all relevant facts to your lawyer.